Basic Information
| Provider Information | |||||||||
| NPI: | 1619107976 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | SMITH | ||||||||
| FirstName: | CONNIE | ||||||||
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| Credential: | APRN | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 1328 | ||||||||
| Address2: | |||||||||
| City: | MOUNT STERLING | ||||||||
| State: | KY | ||||||||
| PostalCode: | 403535328 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8594047686 | ||||||||
| FaxNumber: | 8592740785 | ||||||||
| Practice Location | |||||||||
| Address1: | 209 NORTH MAYSVILLE ROAD | ||||||||
| Address2: | SUITE 200 | ||||||||
| City: | MOUNT STERLING | ||||||||
| State: | KY | ||||||||
| PostalCode: | 40353 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8594047686 | ||||||||
| FaxNumber: | 8592740785 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/21/2009 | ||||||||
| LastUpdateDate: | 01/17/2013 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | 3006148 | KY | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
ID Information
| ID | Type | State | Issuer | Description | 12028306 | 01 | KY | CAQH | OTHER |